MEN, MASCULINITIES AND HIV/AIDS: STRATEGIES FOR ACTION Myra Betron, Gary Barker, Juan Manuel Contreras & Dean Peacock International Center for Research on Women Instituto Promundo MenEngage Alliance Sonke Gender Justice Network ACKNOWLEDGEMENT This publication was generously funded by United Nations Development Programme (UNDP). All opinions, views and conclusions expressed in this publication are those of the author(s) and do not necessarily rep- resent those of the United Nations, including UNDP, or their Member States. Myra Betron from Engender- Health, Gary Barker from Instituto Promundo, Juan Manuel Contreras from International Center for Research on Women, and Dean Peacock from Sonke Gender Justice Network, authored this publication. We extend our special thanks for providing their valuable comments to Piotr Pawlak from Instituto Promundo, James Lang from Partners for Prevention, Susana Fried and Deena Patel from UNDP, and Jenny Drezin, indepen- dent consultant and editor. Cover Photo: (From the top, left): Mozambique – UNDP / India, UNDP / India, UNDP / India – Samrat Mandal, UNDP Sierra Leone – Natsuko Kaneyama, UNDP / Sierra Leone – Natsuko Kaneyama, UNDP / India, UNDP / Nigeria – UNDP Pakistan – Agha Rizwan Ali / Haiti – Augustin Lagneau / Jordan – UNDP / Burundi – UNDP / India – Samrat Mandal, UNDP 2 MEN, MASCULINITIES AND HIV/AIDS: STRATEGIES FOR ACTION TABLE OF CONTENTS INTRODUCTION 4 1. SOCIAL AND BEHAVIOUR CHANGE IN MEN 7 THE ISSUES 7 STRATEGIES FOR ACTION 9 2. VIOLENCE AGAINST WOMEN 10 THE ISSUES 10 STRATEGIES FOR ACTION 11 3. MEN, SEX WORK AND TRANSACTIONAL SEX 14 THE ISSUES 15 STRATEGIES FOR ACTION 16 4. MEN, SUBSTANCE ABUSE AND HIV/AIDS 19 THE ISSUES 19 STRATEGIES FOR ACTION 20 5. MALE CIRCUMCISION 22 THE ISSUES 22 STRATEGIES FOR ACTION 23 6. MEN, VCT AND TREATMENT 25 THE ISSUES 25 STRATEGIES FOR ACTION 26 7. MALE NORMS AND THE CAREGIVING FOR PEOPLE LIVING WITH AND AFFECTED BY HIV/AIDS 28 THE ISSUES 28 STRATEGIES FOR ACTION 29 FINAL RECOMMENDATIONS 31 APPENDIX 1 33 ENDNOTES 35 INTRODUCTION Starting the Discussion: Gender, multiple partners simultaneously, more likely to Masculinities and HIV have a sexual partner outside of their regular or long-term relationship, and more likely to buy sex. Gender norms and the gender-based power dif- In many cultures, variety in sexual partners is seen ferentials between men and women, amongst as essential to the nature of men.3 In practice, this di!erent groups of men, and amongst di!erent means that men will likely have more sex partners groups of women, are key drivers of men’s and on average than women. Conversely, women are women’s vulnerability to HIV. While the concept expected to be sexually passive, discouraged of gender is often perceived to refer primarily to from acquiring knowledge about sex, suggest- women and girls, gender norms shape socially ing condoms or contraceptive use, or accessing acceptable notions of masculinity as well as femi- sexual and reproductive health services. Many of ninity and help de"ne what it means to be a man the world’s women have little power to negotiate as well as a woman. Masculinity, as de"ned in this safer sex, including when, with whom, and how paper, refers to the complex and multiple ways sex occurs. that manhood is socially de"ned across historical and cultural contexts, and to the power di!erences Contemporary patterns of work and living condi- between speci"c versions of manhood or groups tions, which encourage migration or working in of men.1 Gender further encompasses alternate high-risk conditions, and situations of poverty and identities, such as transgender or intersex. social exclusion, which commonly drive sexual ex- ploitation, make both men and women vulnerable The use of a gender perspective in the context of to HIV. Global studies a#rm that high percentages HIV requires us to look at the relations and power of women, girls, transgender people and some hierarchies among all sexes and sexual identities, men and boys, particularly in con$ict settings, have as well as the structural contexts that reinforce and experienced sexual violence. In areas with high HIV create power relations between and among them. incidence, sexual violence increases vulnerability to For example, in much of the world, men are ex- HIV.4 An inability to discuss or question inequitable pected to be sexually knowledgeable and active, aspects of men’s sexual practices has limited HIV and they face pressures to engage in sexual risk prevention e!orts. taking or even violence. Sexual behaviour studies globally indicate that men – whether married or Stigma and discrimination against men who have sex single, heterosexual, homosexual or bisexual – with men (MSM) and transgender individuals also have higher reported rates of partner change than exacerbates HIV vulnerability in a number of ways. women.2 In addition, men are more likely to have Risk factors such as poverty and invisibility along 4 MEN, MASCULINITIES AND HIV/AIDS: STRATEGIES FOR ACTION with negative social attitudes may lead to internal of their families is key to HIV prevention work, as stigma (shame, low self-esteem), thus decreasing is their involvement in mitigating the e!ects of the health-seeking behaviour and increasing sexual epidemic. Changes in the attitudes and behaviours risk-taking. It is important to note, however, the of men and boys, and in unequal power between complex nature of sexual and gender identity and women and men, are essential to prevent HIV in its implications in the context of HIV. For example, women and girls.” not all MSM de"ne themselves as homosexual or In order to e!ectively address the HIV epidemic, we are labeled as such by society at large, which may must understand how social constructions of gen- complicate the ability of health programs to reach der, including masculinities, put both women and them. In some contexts, it is common for MSM also men at risk. Most importantly, we must understand to have sex with women. Social stigma against how these constructions can be transformed using sexual minorities has further precluded passage rights-based approaches. This includes employ- and implementation of laws and policies protecting ing a gender transformative approach that seeks them, as well as the development of HIV prevention to change underlying gender norms, speci"cally campaigns and services explicitly directed toward those related to masculinities. Given what we know sexual minorities. Furthermore, discriminatory and about how these norms and power structures drive homophobic attitudes also may contribute to vul- the epidemic, we can improve the health and well- nerabilities for heterosexual women and men, as being of men and women of all sexual and gender homophobia can be used to reinforce traditional, identities. Gender transformative approaches, as non-equitable views about manhood. All of these referenced throughout this paper, go beyond ad- issues must be included in a gender perspective in dressing the needs, aspirations and capacities of addressing the HIV epidemic. females and males. They also challenge biased and The international community, including the United discriminatory policies, practices, ideas and beliefs Nations, has come to recognize the importance of and attempt to change them.5 Such transforma- a gender perspective and engaging men and boys tive approaches are inherently rights-based as they in programming to address HIV. For example, the include attention to human dignity, the needs and UNAIDS Agenda for Accelerated Country Action for rights of vulnerable groups, and an emphasis on Women, Girls, Gender Equality and HIV (Agenda for ensuring that health systems are made accessible Women and Girls) acknowledges the need for male to all, free from discrimination on the basis of sex involvement in a gender-equitable response to the and gender roles. pandemic: “Men must work with women for gender equality, question harmful de"nitions of masculini- ty and end all forms of violence against women and girls. Men’s responsibility for children and the care INTRODUCTION 5 ORGANIZATION OF THIS PAPER The purpose of this paper is to provide practical guidance to policymakers and program managers on how to engage men and address harmful male norms in seven key areas of intervention in relation to HIV/AIDS: 1 Social and Behaviour Change in Men 2 Violence against women 3 Men, Sex Work and Transactional Sex 4 Men, Substance abuse and HIV/AIDS 5 Male Circumcision 6 Men, VCT and Treatment 7 Male Norms and the Caregiving for People Living with and A!ected by HIV/AIDS The paper provides a brief overview of the issues related to masculinities in each of the above areas and then provides recommended “strategies for action” based on promising practices of engaging men and boys for gender equality and for men’s own gender-related vulnerabilities related to HIV in HIV prevention, care, treatment and support. Most of this paper focuses on policies and programs addressing masculini- ties in the context of heterosexual relations, but it also discusses important "ndings and recommendations in relation to MSM and transgender individuals where relevant and available. The paper closes with "nal cross- cutting strategies for action as well as recommendations for policy and programs on engaging men and boys in addressing the gender dimensions of HIV. An annex (APPENDIX 1) includes a list of related tools and resources that may be useful for policymakers and program managers. 6 MEN, MASCULINITIES AND HIV/AIDS: STRATEGIES FOR ACTION 1. SOCIAL AND BEHAVIOUR CHANGE IN MEN well as information-only based approaches,ii Prevention programmes will not be optimally have proven limited in reducing the risk of HIV.7 e!ective unless they are supported by e!ec- Unless equally aimed at changing men’s behaviour, tive initiatives to address the social factors such approaches are often irrelevant for women that increase risk and vulnerability, including who do not have the choice to abstain, are already gender inequality, HIV stigma and discrimi- the faithful ones in the relationship, and whose nation, and the social marginalization of the partners refuse to use condoms.